Medical Missions – A Critical Perspective

Peter Rohloff has training in parasitology, internal medicine and pediatrics. He practices in Boston, MA at Brigham and Women's Hospital and Boston Children's Hospital. Since 2003, Peter has been working in Guatemala, where he serves as the medical director for a health systems NGO – Wuqu’ Kawoq | Maya Health Alliance. Peter’s interests include the management of chronic diseases of children and adults in resource poor settings and how indigeneity, cultural, and language barriers impact access to and utilization of health care.
@wuqukawoq

Nicole S. Berry is a medical anthropologist based at Simon Fraser University. She is an expert in the anthropology of reproductive health and indigenous health and has conducted extensive research on these topics in the highlands Guatemala. Recently, she has been conducting an anthropological inquiry into medical missions and has just published an article in Social Science & Medicine, Did we do good? NGOs, conflicts of interest and the evaluation of short-term medical missions in Sololá, Guatemala. I recently had the opportunity to talk with her about where research and evaluation on the topic of medical missions needs to be focused.

Can you give us some background on yourself and why you became interest in the topic of medical missions?

As part of my dissertation research on maternal health, I did a lot of interviews with women in Sololá, Guatemala about their experiences in childbirth. A few of the women whom I talked to saw me as an avenue to resolve medical issues. One woman in particular was suffering from a prolapsed uterus. Soon after talking to her, I was buying my groceries and noticed a sign affixed to a telephone pole that advertised a surgical mission that was coming to town. I ended up accompanying the woman I had interviewed to the mission, and she had a vaginal hysterectomy. The week after the mission had left town, one of this woman’s children came to find me to tell me that his mother couldn’t get out of bed. I was panicked. Since I was doing fieldwork in the local hospital at this time, I went there to ask what I should do. The doctor on duty asked me about the surgery, and I realized I couldn’t answer many of his questions (e.g. Did they do any tests or pathology before operating? Was the surgery complicated?). The patient had no records of the procedure with her either. Over the course of the next few days, I frantically called around trying to track down the organizer of the mission. After a few days, I located her, but only to find out that she had put the paper medical records in her basement and it had subsequently flooded. Everything had been ruined.
This experience opened up conversations with doctors in the local hospitals about short-term medical missions. One of the main complaints was that doctors from North America didn’t understand the conditions in Guatemala and therefore didn’t practice correctly. Surgical missions brought doctors from hospitals in Boston, Toronto, New York, Los Angeles — not exactly the proletariat of medicine. These were locations where evidence was gathered and put forth to establish global norms. Yet, somehow, when these doctors practiced in Guatemala, local practitioners viewed them as inept. I found this disjuncture curious.

As time went by and short-term missions became more and more common, I also found that the practice began to symbolize for me a general shift in global health. Recently, global health has been characterized by the waning importance of large international organizations and the increase in number and importance of smaller NGOs. Short-term medical missions are the best example of this new trend in DIY global health development, where individuals band together and try to change health outcomes (rather than going through an established bureaucracy).

Can you comment on the historical development of medical missions? What public health needs are they responding to?

A question about the scope of medical missions take us back hundreds of years, as missionary hospitals and doctor-missionaries were a staple of the colonial landscape. In my article, I’m most interested short-term medical missions. In general these types of missions have only existed since the 1950s, a consequence of the increasing accessibility of international travel. I would say that they have exploded in popularity over the last 15 years, and that is really the period that I am investigating.

The first thing that I would point out is something that I highlight in the article. There seems to be an assumption among (western) publics that short-term medical missions are responding to need. Yet little work goes into to figuring out what constitutes “need”. Short-term medical missions tend to work on a “build it and they will come” model, rather than from an analysis of public health data. This fact is also reflected in the uneven geographical coverage of short-term medical missions, for example in Guatemala, but also globally. Many communities with the poorest health outcomes and worst access to care are untouched by short-term medical missions, while other, more well-off communities receive much aid of this type. It’s difficult to get a bearing on whether or not missions are having a numbers impact when the phenomenon itself is being driven by a fuzzy imagining of the problem and no analysis of what might constitute actual impact.

One point you bringing up your manuscript is how there is a lack of critical literature on missions. Can you give us a sense of why this might be?

There are a number of reasons for this. At the most basic level, I would say that short-term medical missions are fairly new. There is always a 5-10 year lag between the time when a phenomenon emerges and when it gets properly analyzed. I also think that another part of the answer to this question has to do with the structure of missions and what sort of attention might be attracted to them. A majority of medical missions probably have several volunteers on staff with research skills. In this case that expertise is almost always medical and you can easily find peer-reviewed articles about “field medicine” or the efficacy of particular techniques in particular environments. But it seems that lots of the interesting questions about short term medical missions can’t be answered from a strictly medical perspective. For example, recent humanitarian disasters (like the Indian Ocean Tsunami or the earthquake in Haiti) have raised the issue that help offered might not result in help gained. Thus, since 2004, we see a smattering of medical volunteers finally talking about the larger issues at stake—like do short term medical missions really help? But the responses tend to fall short, as reports of surgical production and short-term outcomes at one mission don’t really translate into a robust evaluation.

One of the points you raise several times in your manuscript is how the mission model sets up a dynamic in which the needs and desires of volunteers and medical staff are at odds with the needs and desires of beneficiaries and patients. How do responsible organizations cope with this?

I like the idea of thinking about what it means to be a “responsible organization.” Certainly this isn’t a question restricted to medical missions. I do, however, think that there are particular dynamics that result from the short-term medical missions model that create tensions between the needs and desires of different stakeholders. The lack of an insightful analysis of what constitutes need, as well as the fact that volunteers for the most part have limited experience in the places they work can create problems in terms of understanding what might be best for patients, communities and the future of missions and organizations. Volunteers who arrive to Guatemala typically are left to imagine what needs to be done and how they are helping out. For example, I have heard multiple accounts of veteran surgeons and anesthetists having to reign in rookie surgical volunteers. Rookies can view the risks of undertaking a complicated surgery as outweighing the costs. It’s not difficult to imagine how this comes about—the short-term nature of the mission creates a “do it now or never” situation. Yet, organizers and veterans aren’t as taken in by the short scope of one mission, and this creates a different understanding of benefits and consequences. These conflicts are an inevitable consequence of a model where the short term nature and volunteer turn over always translate into an asymmetrical understanding of organization and patient costs/benefits.

I really like this paragraph from your manuscript:

The current evaluation of medical missions is heavily marked by a dominant emphasis on what matters to providers. Medical efficiency and short-term medical efficacy concerning procedures performed are taken as the proxies for success (Kim et al., 2013). Despite being a dear or even rare good, the delivery of medical care can be quite contentious. Particularly among indigenous people in the Americas, medical encounters have functioned to reinscribe inequalities and oppression (Berry, 2010; Browne, 2007). In such unequal contexts, missions can only be certain that their services do not further perpetuate the injustices that they are trying to address by considering what indigenous and indigent communities they serve see as important (Berry, 2008). They cannot evaluate this by only requesting indigenous patients’ evaluations of what the provider thinks is important (e.g. wait times, treatment by staff, biomedical skill, etc.).

The overall point of this paragraph is really to push back against narratives that transparently elevate access to curative care as a good thing. In this article I write about short-term medical missions as a facet of contemporary humanitarianism, and humanitarianism seems to be defined by stepping into the fray and doing something that needs to be done. Yet, even in the most desperate circumstances, we have seen that it’s ethically irresponsible to assume that care delivery in and of itself is “helpful.”

This general point could be taken up from a variety of perspectives, but I like to emphasize research that demonstrates unfortunate outcomes of medical encounters for indigenous peoples. We need to remember that issues of race/ethnicity get drawn into the power dynamics of the medical encounter. From a biomedical perspective, a treatment may be successful, but from the perspective of a patient who is stereotyped or harassed, the interaction can be traumatic. For me, the most obvious danger for short-term medical missions clusters around the issues of creating a dependent relationship. As one former volunteer remarked, by stepping in and filling a need, he felt he was making sure that no one from the community would ever be empowered to fill that need themselves.

Volunteers and organizers also talk about another facet of this dependency that I write about in the article: short-term medical missions can contribute to indigenous communities devaluing their local health resources. This devaluation is compounded because the familiar ethnic tensions that might mark local encounters are frequently absent from short-term medical missions. But a lack of racism on the part of the short-term provider does not erase the potential effects of power differentials. For example, if carrying out medical activities in indigenous languages can arguably revitalize them, than not carrying out medical activities in indigenous languages arguably contributes to language shift. Part of this shift can be pegged to volunteers inadvertently modeling global power dynamics, where indigenous people are on the “powerless” end. This point was hammered home for me in an interview with the husband of a woman who received care at a short term medical mission. When I asked him what the mission could do better, he said that that was not for him to say. He is the one who asks or begs (pedir, in Spanish). He stressed that it was for me and the people who came to do the mission to decide what will be done. It was for him to receive. Think about this. What does it mean to grow up in a world where everyone who is a “beggar” is indigenous and the “choosers” who originate and bring solutions are not? If you were indigenous, how would this impact how you felt about your community? Your language? Your culture? For me these are real questions to be wrangled with, and sweeping them under the rug as impractical because Northern volunteers don’t speak indigenous languages isn’t a sufficient answer.

For this reason, I think that the article is focused on the lack of discussion about when a mission shouldn’t occur. Ethically, I would respect an organization that opened up these conversation and came out the other end deciding that their short-term medical mission efforts were in line with how they envisioned positive change happening. The problem is that I don’t see much conversation about the wider effects and downsides of short term medical missions (outside of medical outcomes).

Medical missions – do they do more harm or more good?

At the most fundamental level, I think this is a political question. Kim, Farmer and Porter do a nice job of separating out how different parties will assign different value to the same aspect of health care delivery. As they point out, a patient and her family will assign almost infinite value to a life-saving therapy, while a planner in the Ministry of Health might find the same expensive therapy as deleterious to overall goals. I think that there are a lot of individual patients who recover immense value from short-term medical missions and whose lives are changed by the care that they receive.

However, if you look at Kim, Farmer and Porter, two of whom are heads of major international organizations, their politics push them against stand-alone efforts like these. They speak to the importance of systems that establishes value. From their perspective, people exist within these systems. Given that, it is impossible to establish the “harm” or the “good” of a short-term medical mission by looking at its performance alone. So again, from this perspective, were short-term medical missions to refuse to coordinate, articulate and mainstream themselves within and with respect to larger structures, then they would be seen as offering little good. While theoretically, I am a strong proponent of strong health systems and enjoy thinking from this perspective, I also recognize that while the plethora of health NGOs working in, for example, Guatemala may create chaos, this may not be the only or most important challenge that the health system itself faces. Guatemala suffers from a chronically underfunded health system that is constantly having to respond to the vagaries of politics. It’s difficult to imagine how this can or will change. Therefore, I sympathize with the general NGO attitude of “something needs to be done and I can do it.” However, as I pointed out above, the sanctity of knowing that someone has been helped does not remove the responsibility of figuring what you are doing and why.